Presentation on theme: "The Essentials 5th Annual CE LHIN CME"— Presentation transcript:
1The Essentials 5th Annual CE LHIN CME Canadian Diabetes Association 2013 Clinical Practice GuidelinesThe Essentials 5th Annual CE LHIN CME
2Dr. John Sigalas Endocrinologist Rouge Valley Health System Toronto May 15 , 2013
3Learning ObjectivesBy the end of this session, participants will be able to:Understand the major changes within the 2013 CDA clinical practice guidelinesUnderstand the rationale behind these changesApply the recommendations in clinical practice
4Faculty for slide deck development Jonathan Dawrant, BSc, MSc, MD, FRCPCZoe Lysy, MDCM, FRCPCGeetha Mukerji, MD, FACP, FRCPCDina Reiss, MD, FACP, FRCPCSteven Sovran, BSc, MD, MA, FRCPCAlice Y.Y. Cheng, MD, FRCPCPeter J. Lin, MD, CCFPCatherine Yu, MD, FRCPC, MHSc
6Reorganize his history Victor59 years oldType 2 DiabetesHe has EVERY complication of DiabetesThat is what we need to avoidTIA 2005Stroke 2006PAD 2002Ischemic Toes Amputation 2004MI 2003MI 2004Bypass 2001ACS 2001MacrovascularNeuropathy 2003CKD 2002Retinopathy 2004MicrovascularNeuropathy 2002
10Fasting = no caloric intake for at least 8 hours Diagnosis of Diabetes2013FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hoursorA1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the accuracy of the A1C and not for suspected type 1 diabetes2hPG in a 75-g OGTT ≥11.1 mmol/LRandom PG ≥11.1 mmol/LRandom= any time of the day, without regard to the interval since the last mealScript:Diabetes can be diagnosed by many different cut-offs. The biggest change from the previous set of guidelines is that HbA1c > 6.5% is part of diagnostic cut-off if a standardized validated assay is used with absence of other factors that affect A1c and not suspecting Dm. So FBG >7, A1c >6.5%, or 2h PG > 11.1 or random PG >11.1 can be used to used to diagnose diabetes.Diagnosis of diabetes is based on thresholds of glycemia that are associated with microvascular disease2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose
11Diagnosis of Prediabetes* 2013TestResultPrediabetes CategoryFasting Plasma Glucose(mmol/L)Impaired fasting glucose (IFG)2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)7.8 – 11.0Impaired glucose tolerance (IGT)GlycatedHemoglobin(A1C) (%)Prediabetes* Prediabetes = IFG, IGT or A1C % high risk of developing T2DM
12Individualizing A1C Targets 2013Consider % if:which must be balanced against the risk of hypoglycemia
13Diabetes in Canada: Prevalence by Province and Territory Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09< 5.05.0 < 5.55.5 < 6.06.0 < 6.5≥ 6.5YT5.4%NT5.5%NU4.4%NL6.5%BC5.4%AB4.9%MB5.9%Source: Public Health Agency of Canada (September 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).PE5.6%SK5.4%QC5.1%ON6.0%NS6.1%NB5.9%† Age-standardized to the 1991 Canadian population.NL, NS and ON had the highest prevalence, while NU, AB and QC had the lowest.Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.13
14Diabetes in Canada: Prevalence of Diagnosed Diabetes by age and sex Prevalence of diagnosed diabetes among individuals aged ≥ 1 year, by age group and sex, 2008/09Overall Prevalence306.4%Females257.2%Males20Total6.8%Prevalence (%)1510Source: Public Health Agency of Canada (July 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).5Age group (years)1-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84≥85CanadaPrevalence increased with age. The sharpest increase occurred after age 40 years. The highest prevalence was in the year age group.Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.14
15Patients with DM are more likely to be hospitalized for many conditions Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).
16Guideline Targets Achieved % of patientsABSTRACTObjective: To gain insight into the current management of patients with type 2 diabetes mellitus (T2DM)by Canadian primary care physicians.Methods: 479 primary care physicians from across Canada submitted data on 5123 T2DM patients whomthey had seen on a single day on or around World Diabetes Day, November 14th, 2012.Results: Mean A1C was 7.4%, LDL-C 2.1 mmol/L and blood pressure 128/75 mmHg. A1C≤7.0% wasmet by 50%, LDL-C ≤2.0 mmol/L by 57%, BP <130/80 mmHg by 36% and the composite triple target by13% of patients. Diet counselling had been offered to 38% of patients. Of the 87% prescribedantihyperglycemic agents, 18% were on 1 non-insulin antihyperglycemic agent (NIAHA) (85% of whichwas metformin), 15% 2 NIAHAs, 6% ≥3 NIAHAs, 19% insulin only and 42% insulin+≥1 NIAHA(s).Amongst the 81% prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was astatin). Amongst the 83% prescribed antihypertensive agents, 39%, 34% and 21% and 6% received 1, 2,3 and >3 drugs, respectively, with 59% prescribed angiotensin-converting enzyme inhibitors and 35%angiotensin II receptor blockers.Conclusion: The DM-SCAN survey highlights the persistent treatment gap associated with the treatmentof T2DM and the challenges faced by primary care physicians to gain glycemic control and globalvascular protection in these patients. It also reveals a higher use of insulin therapy in primary carepractices relative to previous surveys. Practical strategies aimed at more effectively managing T2DMpatients are urgently needed.Leiter LA et al. Can J Diabetes 2013; in press16
17Self-Monitoring of Blood Glucose (SMBG) What should we tell patients to do?
19Increased frequency of SMBG may be required: Daily SMBG is not usually required if patient:
20Pharmacotherapy in T2DM checklist 2013CHOOSE initial therapy based on glycemiaSTART with Metformin +/- othersINDIVIDUALIZE your therapy choice based on characteristics of the patient and the agentREACH TARGET within 3-6 months of diagnosis
21L I F E S T Y 2013 AT DIAGNOSIS OF TYPE 2 DIABETES Start lifestyle intervention (nutrition therapy and physical activity) +/- MetforminA1C <8.5%A1C 8.5%Symptomatic hyperglycemia with metabolic decompensationIf not at glycemic target (2-3 mos)Start metformin immediatelyConsider initial combination with another antihyperglycemic agentInitiate insulin +/-metforminStart / Increase metforminIf not at glycemic targetsAdd an agent best suited to the individual:Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOtherAgent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOtherMay start Metformin at the time of diagnosisChange to 8.5% as thresholdStart metformin immediately as an optionConcept of individualizing therapy based on patient and agent characteristicsWith that in mind, the next figure shows the characteristics of the agents ….2013See next page…
22Make timely adjustments to attain target A1C within 3-6 months From prior page…LIFESTYConcept of RELATIVE A1c lowering – not absoluteConcept of RELATIVE cost considerationsChange to achieve target within 3-6 months.If not at glycemic targetAdd another agent from a different classAdd/Intensify insulin regimen2013Make timely adjustments to attain target A1C within 3-6 months
23Patient Characteristics Agent Characteristics AT DIAGNOSIS OF TYPE 2 DIABETESLIFESTYStart lifestyle intervention (nutrition therapy and physical activity) +/- MetforminA1C < 8.5%A1C 8.5%Symptomatic hyperglycemia with metabolic decompensationIf not at glycemic target (2-3 mos)Start metformin immediatelyConsider initial combination with another antihyperglycemic agentInitiate insulin +/-metforminStart / Increase metforminIf not at glycemic targetsAdd an agent best suited to the individual:Patient CharacteristicsDegree of hyperglycemiaRisk of hypoglycemiaOverweight or obesityComorbidities (renal, cardiac, hepatic)Preferences & access to treatmentOtherAgent CharacteristicsBG lowering efficacy and durabilityRisk of inducing hypoglycemiaEffect on weightContraindications & side-effectsCost and coverageOtherMay start Metformin at the time of diagnosisChange to 8.5% as thresholdStart metformin immediately as an optionConcept of individualizing therapy based on patient and agent characteristicsWith that in mind, the next figure shows the characteristics of the agents ….2013See next page…
25Antihyperglycemic agents and Renal Function Not recommended / contraindicatedSafeCaution and/or dose reductionRepaglinideMetformin3060SaxagliptinLinagliptinGlyburide50ThiazolidinedionesGFR (mL/min):< 1515-2930-5960-89≥ 90CKD Stage:54321Gliclazide/Glimepiride15LiraglutideExenatideAcarbose25Sitagliptin2.5 mg50 mg25 mgAdapted from: Product Monographs as of March 1, 2013; CDA Guidelines 2008; and Yale JF. J Am Soc Nephrol 2005; 16:S7-S10.
32Definition of Hypoglycemia Development of neurogenic or neuroglycopenic symptomsLow blood glucose (<4 mmol/L if on insulin or secretagogue)Response to carbohydrate loadNeurogenic (autonomic)NeuroglycopenicTremblingDifficulty ConcentratingPalpitationsConfusionSweatingWeaknessAnxietyDrowsinessHungerVision ChangesNauseaDifficulty SpeakingDizzinessThe CDA defines hypoglycemia as the development of autonomic (trembling, palpitations, sweating, anxiety, hunger, nausea, tingling) or neuroglycopenic (difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness) symptoms, a low plasma glucose, and symptoms responding to the administration of a carbohydrate. In mild to moderate hypoglycemia, blood glucose is <4 mmol/L, autonomic and/or neuroglycopenic symptoms are present, but the patient is able to self-treat. However, patients who maintain a higher blood glucose level may experience hypoglycemia at levels >4.0 mmol/L. Severe hypoglycemia indicates the patient is unable to treat the reaction without outside assistance. He/she may or may not be conscious.32
33Steps to Address Hypoglycemia Recognize autonomic or neuroglycopenic symptomsConfirm if possible (blood glucose <4.0 mmol/L)Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptomsRetest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if neededEat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus proteinTeaching patients to recognize and treat hypoglycemia can be done in 3 steps1) It is important to teach patients to recognize the common autonomic and neuroglycopenic symptoms associated with hypoglycemia including: Trembling, Palpitations, Sweating, Anxiety, Hunger, Nausea, Tingling which are common autonomic symptoms and Difficulty concentrating, Confusion, Weakness, Vision change, and Headache are common neuroglycopenic symptoms.
34Macrovascular Disease Vascular Protection: Who and When?
35Vascular Protection Checklist 2013A • A1C – optimal glycemic control (usually ≤7%)B • BP – optimal blood pressure control (<130/80)C • Cholesterol – LDL ≤2.0 mmol/L if decided to treatD • Drugs to protect the heartA – ACEi or ARB │ S – Statin │ A – ASA if indicatedE • Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weightS • Smoking cessation
36Who Should Receive Statins? 2013≥40 yrs old orMacrovascular disease orMicrovascular disease orDM >15 yrs duration and age >30 years orWarrants therapy based on the 2012 Canadian Cardiovascular Society lipid guidelinesAmong women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception.
37Who Should Receive ACEi or ARB Therapy? 2013Who Should Receive ACEi or ARB Therapy?≥55 years of age orMacrovascular disease orMicrovascular diseaseAt doses that have shown vascular protection (ramipril 10 mg daily, perindopril 8 mg daily, telmisartan 80 mg daily)Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy
39No. of events/No. in group ASAControl/placeboRR (95% CI)RR (95% CI)Major CV eventsASA for 1⁰ Prevention in Diabetes Meta analysis of 6 studies (n = 10,117)JPADPOPADADWHSPPPETDRSTotal68/1262105/63858/51420/519350/1856601/478986/1277108/63862/51322/512379/1855657/47950.80 ( )0.97 ( )0.90 ( )0.90 ( )0.90 ( )0.90 ( )Myocardial infarctionJPADPOPADADWHSPPPETDRSPHSTotal28/126290/63836/5145/519241/185611/275395/506414/127782/63824/51310/512283/185526/258439/50530.87 ( )1.10 ( )1.48 ( )0.49 ( )0.82 ( )0.40 ( )0.86 ( )No overall benefit for:Major CV eventsMIStrokeCV mortalityAll-cause mortalityStrokeJPADPOPADADWHSPPPETDRSTotal12/126237/63815/5149/51992/1856181/478932/127750/63831/51310/51278/1855201/47950.89 ( )0.74 ( )0.46 ( )0.89 ( )1.17 ( )0.83 ( )Death from CV causesThis meta-analysis examined whether ASA is beneficial for patients with diabetes who have no clinical evidence of CVD. Of 6 eligible studies included in the meta-analysis of over 10,000 participants, there is no statistically significant reduction in the risk of Major CV events, MI, stroke, CV mortality or all-cause mortality when ASA was compared with placebo for primary prevention among patients with diabetes.Of 157 studies in the literature searches, six were eligible (10,117 participants). When ASA was compared with placebo, there was no statistically significant reduction in the risk of major CV events (five studies, 9,584 participants; RR 0.90; 95% CI ), CV mortality (four studies, 8,557 participants; RR 0.94; 95% CI ), or all-cause mortality (four studies, 8,557 participants; RR 0.93; 95% CI ).Significant heterogeneity was found in the analyses for MI (I2 = 62.2%; p = 0.02) and stroke (I2 = 52.5%; p = 0.08). ASA significantly reduced the risk of MI in men (RR 0.57; 95% CI ) but not in women (RR 1.08; 95% CI ; p for interaction = 0.056). Evidence relating to harms was inconsistent.These authors concluded that a clear benefit of ASA in the primary prevention of major CV events in people with diabetes remains unproved, that sex may be an important effect modifier, and that toxicity is to be explored further.The analysis shows ASA has benefit for men in prevention of MI but not for stroke prevention, but no benefit in women for either MI or stroke preventionReference:De Berardis G, Sacco M, Strippoli GF, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. BMJ 2009; 339:b4531.JPADPOPADADPPPETDRSTotal1/126243/63810/519244/1856298/427510/127735/6388/512275/1855328/42820.10 ( )1.23 ( )1.23 ( )0.87 ( )0.94 ( )JPAD = Japanese Primary Prevention of Atherosclerosis with Aspirin for DiabetesPOPADAD = Prevention of Progression of Arterial Disease and DiabetesPPP = Primary Prevention ProjectETDRS = Early Treatment Diabetic Retinopathy StudyPHS = Physicians’ Health StudyWHS = Women’s Health StudyDe Beradis G, et al. BMJ 2009; 339:b4531.All-cause mortalityJPADPOPADADPPPETDRSTotal34/126294/63825/519340/1856493/427538/1277101/63820/512366/1855525/42820.90 ( )0.93 ( )1.23 ( )0.91 ( )0.93 ( )20.030.1250.518Favors ASAFavors control/placebo
40Summary of Pharmacotherapy for Hypertension in Patients with Diabetes Threshold equal or over 130/80 mmHg and Target below 130/80 mmHgCombination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above targetWith Nephropathy, CVD or CV risk factorsACE Inhibitor or ARBDiabetesWithoutthe above1. ACE Inhibitor or ARB or2. Thiazide diuretic or DHP-CCB> 2-drug combinations1. Persons with diabetes mellitus should be treated to attain systolic blood pressure of lower than130 mmHg (Grade C) and diastolic blood pressure of less than 80 mmHg (Grade A). (These target blood pressure levels are the same as the blood pressure treatment thresholds.) Combination therapy using two first-line agents may also be considered as initial treatment of hypertension (Grade B) if the SBP is 20 mmHg above the target or if DBP is 10 mmHg above the target. However caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or poorly tolerated (e.g. elderly patients, patients with autonomic neuropathy).2. For persons with cardiovascular or kidney disease, including microalbuminuria or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A).3. For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), angiotensin receptor blockers (Grade B), dihydropyridine CCBs (Grade A) and thiazide/thiazide-like diuretics (Grade A).4. If target blood pressures are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide (Grade A).Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARBCombinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuriaMore than 3 drugs may be needed to reach target valuesIf Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired40
41Vascular Protection Checklist 2013A • A1C – optimal glycemic control (usually ≤7%)B • BP – optimal blood pressure control (<130/80)C • Cholesterol – LDL ≤2.0 mmol/L if decided to treatD • Drugs to protect the heartA – ACEi or ARB │ S – Statin │ A – ASA if indicatedE • Exercise – regular physical activity, healthy diet, achieve and maintain healthy body weightS • Smoking cessation
42What if we did all the right things What if we did all the right things? How much could we protect our patients?
43STENO-2: Intensive Group Achieved Targets Patients in the intensive arm significantly achieved targets for glycemia (A1c<6.5%), cholesterol < 175 mg/dL, SBP < 130 and DBP < 80 compared to the conventional arm in the study.Gaede et al. NEJM. 2003: 348;
44Intensive Group had Improved CV Outcomes 60P = 0.0075053 % RRRAny CV eventNNT = 5Conventional therapy40Intensive therapy3020Intensive Therapy Resulted in Improved Combined CV OutcomesSignificantly fewer primary endpoints (a composite of CV death, non-fatal stroke or MI, revascularization, or amputation) occurred in the Intensive treatment group.101224364860728496Months of Follow-upRRR= relative risk reductionGaede et al. NEJM. 2003: 348;
45STENO 2 Extended Follow-up: Effect of a multi- factorial vascular protective strategy on total mortality605040302010Total mortality (%)3Years of follow-up12456789111213Conventional therapyIntensive therapyEND OF TRIALHR = 0.54 ( )p = 0.015Effect of a multifactorial intervention on mortality in type 2 diabetes.Gaede P, Lund-Andersen H, Parving HH, Pedersen O.Steno Diabetes Center, Copenhagen, Denmark.PMID: [PubMed - indexed for MEDLINE]Intensified multifactorial intervention—with tight glucose regulation and the use of renin-angiotensin system blockers, ASA, and lipid-lowering agents—has been shown to reduce the risk of nonfatal CVD among patients with type 2 diabetes and microalbuminuria. The STENO 2 trial evaluated whether this approach would have an effect on the rates of death from any cause and from CV causes.In the STENO 2 Study, 160 patients with type 2 diabetes and persistent microalbuminuria were randomly assigned to receive either intensive therapy or conventional therapy; the mean treatment period was 7.8 years. Patients were subsequently followed observationally for a mean of 5.5 years, until December The primary endpoint at 13.3 years of follow-up was the time to death from any cause.Twenty-four patients in the intensive-therapy group died, as compared with 40 in the conventional-therapy group (HR 0.54; 95% CI 0.32 to 0.89; p = 0.02). Intensive therapy was associated with a lower risk of death from CV causes (HR 0.43; 95% CI 0.19 to 0.94; p = 0.04) and of CV events (HR 0.41; 95% CI 0.25 to 0.67; p < 0.001). One patient in the intensive-therapy group had progression to end-stage renal disease, as compared with six patients in the conventional-therapy group (p = 0.04). Fewer patients in the intensive-therapy group required retinal photocoagulation (RR 0.45; 95% CI 0.23 to 0.86; p = 0.02). Few major side effects were reported.In at-risk patients with type 2 diabetes, intensive intervention with multiple drug combinations and behavior modification had sustained beneficial effects with respect to vascular complications and on rates of death from any cause and from CV causes.Gaede et al. N Engl J Med. 2008; 358(6):
47What about Microvascular Disease? NephropathyRetinopathyNeuropathy
48Chronic Kidney Disease (CKD) Checklist 2013Chronic Kidney Disease (CKD) ChecklistSCREEN regularly with random urine albumin creatinine ratio (ACR) and serum creatinine for estimated glomerular filtration rate (eGFR)DIAGNOSE with repeat confirmed ACR ≥ 2.0 mg/mmol and/or eGFR < 60 mL/minDELAY onset and/or progression with glycemic and blood pressure control and ACE inhibitor or angiotensin receptor blocker (ARB)PREVENT complications with “sick day management” counselling and referral when appropriateUse same check marks as Geetha
49Counsel all Patients About Sick Day Medication List 2013
50Retinopathy Checklist 2013SCREEN regularlyDELAY onset and progression with glycemic and blood pressure control ± fibrateTREAT established disease with laser photocoagulation, intra-ocular injection of medications or vitreoretinal surgeryUse same check marks as Geetha
51Delaying Retinopathy Glycemic control: target A1C ≤7% Blood pressure control: target BP <130/80Lipid-lowering therapy: fibrates have been shown to decrease progression and may be considered2013
52PREVENT with blood glucose control Neuropathy Checklist2013PREVENT with blood glucose controlSCREEN with monofilament or tuning forkTREAT pain symptoms with anticonvulsants or antidepressantsUse Geetha’s check marks
53Recommendation 42013The following agents may be used alone or in combination for relief of painful peripheral neuropathy:Anticonvulsants (pregabalin [Grade A, Level 1], gabapentin‡, valproate‡) [Grade B, Level 2]Antidepressants (amitriptyline‡, duloxetine, venlafaxine‡) [Grade B, Level 2]Opioid analgesics (tapentadol ER, oxycodone ER, tramadol) [Grade B, Level 2]Topical nitrate spray [Grade B, Level 2]‡This drug is not currently approved by Health Canada for the management of neuropathic pain associated with diabetic peripheral neuropathy.
54Why diagnose and treat GDM? MacrosomiaShoulder dystocia and nerve injuryNeonatal hypoglycemiaPreterm deliveryHyperbilirubinemiaCaesarian sectionOffspring obesity (?)Offspring diabetes (?)
55Need a PRECONCEPTION checklist for women with pre-existing diabetes 2013Need a PRECONCEPTION checklist for women with pre-existing diabetes1. Attain a preconception A1C of ≤ 7.0% (if safe)2. Assess for and manage any complications3. Switch to insulin if on oral agents4. Folic Acid 5 mg/d: 3 mo pre-conception to 12 weeks post-conception5. Discontinue potential embryopathic meds:Ace-inhibitors/ARB (prior to or upon detection of pregnancy)Statin therapyScript:
57Recommendation 8-9: Management in Pregnancy for pre-gestational diabetes Women with pregestational diabetes may use aspart or lispro in pregnancy instead of regular insulin to improve glycemic control and reduce hypoglycemia [Grade C level 2 for aspart , Grade C, Level 3 for lispro].Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may be used in women with pregestational diabetes as an alternative to NPH.20132013
58What about insulin analogues and oral agents among patients with GDM? May use rapid-acting analog insulin for postprandial glucose control – no difference in perinatal outcomesMay use glyburide or metformin for women who are non-adherent to or who refuse insulinLikely safe BUT it is OFF- Label no long-term data, need discussion with patient
59“Neither evidence nor clinical judgment alone is sufficient “Neither evidence nor clinical judgment alone is sufficient. Evidence without judgment can be applied by a technician. Judgment without evidence can be applied by a friend. But the integration of evidence and judgment is what the healthcare provider does in order to dispense the best clinical care.”(Hertzel Gerstein, 2012)
60CDA Clinical Practice Guidelines – for professionals1-800-BANTING ( )– for patients